Provider Demographics
NPI:1255638623
Name:SMITH, MELANIE JO
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:374 E 400 S STE 2
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-1976
Mailing Address - Country:US
Mailing Address - Phone:801-615-0554
Mailing Address - Fax:801-515-6243
Practice Address - Street 1:374 E 400 S STE 2
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-1976
Practice Address - Country:US
Practice Address - Phone:801-615-0554
Practice Address - Fax:801-515-6243
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8173947-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist